Application Letter of Instruction

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Aubrey Wheeler
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1 STATE OF NEVADA BOARD OF OCCUPATIONAL THERAPY P.O. BOX Reno, Nevada (775) / Fax: (775) / Toll Free: (800) / Website: TYPES OF LICENSES AVAILABLE Application Letter of Instruction Active License - Applicants must have current certification by NBCOT. An occupational therapist or occupational therapy assistant who intends to practice occupational therapy in the State of Nevada may apply for an active license. An active license will expire twelve (12) months from date of issuance, and may be renewed annually. The license renewal period begins 60 days prior to the date of expiration of the license. Temporary License - Applicants must have current certification by NBCOT. A temporary license may be requested by an individual who: (1) Is an occupational therapist or occupational therapy assistant who is licensed in another state and intends to practice in this state for a period of less than 12 months; or (2) Is a veteran or military spouse who requests expedited processing pending receipt of documentation requirements required for an active license in the State of Nevada. A temporary license will expire six (6) months from the date on which it was issued and may be renewed for one additional 6-month period. A temporary license may be converted to an active license. Provisional License Applicants must be a graduate of a school of occupational therapy. A provisional license may be requested by a person who: (1) is a graduate of a school of occupational therapy but has not taken or passed the NBCOT examination; or (2) an occupational therapist or occupational therapy assistant who was previously certified but does not have current certification by NBCOT and has not practiced occupational therapy for 5 years or more. A provisional license will expire six (6) months from the date on which it was issued. A provisional license may be renewed for one additional 6-month period. A provisional license may be converted to an active license when the licensee obtains current NBCOT certification. Applications and Fees Payment must be submitted at time of application. Incomplete applications, or applications received without payment will be returned to the applicant. Fees may be paid by credit card through our website, Click to Pay, or by check or money order payable to the Board of Occupational Therapy.

2 State of Nevada Board of Occupational Therapy Application Letter of Instruction Page 2 REQUIRED DOCUMENTATION AND INFORMATION ALL LICENSES: Completed Application for Licensure - Applications are required to be notarized, contain original signatures, and a photograph, no less than 2 x 2 must be affixed. Verification of Certification Current certification status must be submitted with your application. Acceptable documentation: on-line verification printout from NBCOT; or request written verification from NBCOT to be sent directly to the Board. Educational Transcripts - An official transcript from the school, college or university where you received your qualifying degree is required. The official transcript may be sent directly from the school or attached in a sealed envelope. Verification of Licensure in Another State Verification of your license status and disciplinary history must be provided for all jurisdictions in which you have held a license in the previous 5 years. Acceptable documentation for verification purposes: Written verification received directly from the regulatory entity; or On-line verification printout from official regulatory entity website dated within 10 days of date of application; or electronic verification received directly from the regulatory entity. Veterans / Military Spouses Expedited processing may be requested by completing the Veteran / Military Spouse certification. A copy of all current licenses are required to be attached to the application pending official verification of license status in another state. Provisional License Applications In addition to the requirements for an Active license; with the exception of NBCOT certification: NBCOT Confirmation of Examination Registration and Eligibility to Examine Submit request directly to NBCOT with applicable fee. NBCOT forms and applicable fees can be obtained from the NBCOT website Confirmation must be sent directly to the Board by NBCOT. Note: NBCOT Score Report or Verification of Certification is required for conversion to active license. Additional Documentation Requirements Upon Licensure Supervisory Change Report All COTA and provisional licensees are required to be under the supervision of a Nevada licensed occupational therapist. Completed form must be submitted to the Board within 15 days from start of employment in Nevada. Employment Change Report Completed form must be submitted within 15 days from start of employment in Nevada. Subsequent changes must be reported within 30 days of that change.

3 State of Nevada Board of Occupational Therapy Application Letter of Instruction Page 3 WHAT TO EXPECT Application Processing Timeline Please allow 3-5 weeks from date of application for receipt of all required documentation and processing. Communication with the Board - Status of license applications can be requested by or telephone. Reciprocity - All applicants must meet Nevada licensure requirements. Veterans and Military spouses who are licensed in another State are eligible for a temporary license pending receipt of required licensure documentation. Incomplete Applications Documentation required to complete License Applications must be received within 90 days from date of submittal of the application or the application will be returned as incomplete. Additional Information - Please contact the Board office for addition information. LICENSE FEE SCHEDULE The fee schedule includes the non-refundable application processing fee of $ OTR COTA Active License $ $ Temporary License $ $ Provisional License $ $

STATE OF NEVADA BOARD OF OCCUPATIONAL THERAPY P.O. BOX 34779 Reno, Nevada 89533-4779 (775) 746-4101 / Fax: (775) 746-4105 / Toll Free: (800) 431-2659 Email: board@nvot.

4 STATE OF NEVADA BOARD OF OCCUPATIONAL THERAPY P.O. BOX Reno, Nevada (775) / Fax: (775) / Toll Free: (800) / Website: Personal Data Legal Name: Mailing LICENSE APPLICATION Active Temporary Provisional Occupational Therapist Occupational Therapy Assistant Street / P.O. Box City State ZIP Social Security No.: Home Phone ( ) Alternate / Cell Phone ( ) US Citizen or Authorized to Work in the US Date of Birth Place of Birth Sex Maiden/Other Names Used effective date(s): NBCOT Certification Status Are you currently certified by NBCOT? Certification No. If NO - have you applied for renewal? Date Submitted New Graduates Only Are you scheduled to take the NBCOT national examination? Date Taken Passed: or Date Scheduled Education / Training Educational Institution/City/State: Date Graduated Major Degree Awarded Professional Licensing History (attach additional sheets if necessary) Are you now or have you ever been licensed, certified or registered as an occupational therapist or occupational therapy assistant in any jurisdiction? Yes No State/Jurisdiction: License #: Issue Date Expiration Date State/Jurisdiction: License #: Issue Date Expiration Date State/Jurisdiction: License #: Issue Date Expiration Date BOARD USE ONLY License No. Date Issued Date Received: Fees Paid: Credit Card or Money Order /Check # Amount: Transcripts NBCOT Verification License Verification(s) R7.1.15

5 Page 2 Professional Employment History (5 years) attach additional sheets if necessary 1. Current Nevada Employer: Start Date 2. Employer: Dates (From/To) 3. Employer: Dates (From/To) 4. Employer: Dates (From/To) Professional References Within the past 5 Years 1. Name: 2. Name: 3. Name: Child Support Information Please check one appropriate answer. An answer is mandatory I am not subject to a court order for the support of a child. I am subject to a court order for the support of one or more children and am in compliance with the order or am in compliance with a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. I am subject to a court order for the support of one or more children and am NOT in compliance with the order or a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. Legal Information Explain any YES answers on a separate sheet of paper Has there ever been a complaint filed, investigation or legal action taken against your professional license for any reason? Are there any pending legal actions, complaints, investigations or hearings in process? Have you ever had a professional license, certification or registration denied, restricted, suspended or revoked? Have you ever relinquished responsibilities, resigned a position or been fired while a complaint was pending against you? Have you ever been convicted of, or pled guilty or nolo contendere to, a violation of ANY federal or state statute, city or county ordinance, or any law of a foreign country? (Exclude minor traffic violations.) R7.1.15

6 Page 3 Acknowledgement and Declaration of Applicant Notice as Mandatory Reporter I acknowledge I have been informed of my duty as a mandatory reporter of abuse or neglect of a child pursuant to NRS 432B. Veteran / Military Spouse: Expedited processing / temporary license requested. I declare that verifying documentation has been requested to fulfill the requirements for licensure in Nevada. I declare, under penalty of perjury, all the information supplied herein is to the best of my knowledge true, accurate and complete and I have not withheld, misrepresented, or falsely stated any information relevant to my training or experience or my fitness to practice occupational therapy. Signature of Applicant Date of Application Print Name Notary Public Stamp Notary Public Signature Affix Photograph Here Date Signed R7.1.15

OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST

STATE OF UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING APPLICATION FOR LICENSURE OCCUPATIONAL THERAPY ASSISTANT or OCCUPATIONAL THERAPIST APPLICATION INSTRUCTIONS AND INFORMATION General Statement: